ISSUE
DATE
# OF
ITEMS
REISSUE
DATE
COST
RETURN
DATE
COLLECTED
BY (INITIAL)
________ _____________
__________________________ _______
Date Supervisor's Signature Date
________ __________
__________________________ _______
Date Supervisor's Signature Date
ATU-031309
_________________________________
Employee's Signature
EMPLOYEE'S NAME:
T NUMBER:
EMPLOYEE'S HOME ADDRESS:
Employee's Signature
_________________________________
SUPERVISOR'S NAME:
SUPERVISOR'S WORK PHONE:
SUPERVISOR'S CAMPUS ADDRESS:
DESCRIPTION OF ITEM
DEPARTMENT:
EMPLOYEE'S POSITION:
EMPLOYEE'S TELEPHONE NUMBER: